Monthly Archives: March 2012

There is a transformation occurring in health care. What traditionally had been the responsibility of payers is now shifting to providers. Providers and health systems haven’t been responsible for comparing the total cost of care against total health outcomes. As part of this transformation, health systems will increasingly be held accountable for total costs of care.

My concern about putting the “accountable” in “accountable care” is measurement. What will be measured? How does a provider or health system that traditionally has billed for services now assume responsibility for the total cost of care? Continue reading →

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As promised, I am going to talk about chronic conditions that are common enough that most physicians see patients who have them. And that means dealing with the documentation needs for coding the patient encounter in ICD-9 now and ICD-10 in the future. In this blog I am going to highlight the similarities and differences between ICD-9 and ICD-10 documentation and coding needs for diabetes and congestive heart failure (CHF).

Diabetes Diabetes coding will actually be easier and more efficient in ICD-10, which should translate into fewer queries from coders. There are two basic changes in ICD-10 diabetes classification:

No more coding and documentation hassles with uncontrolled diabetes.

Complex diabetes cases that required multiple ICD-9 codes can be coded with one ICD-10 code.

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Since the recent announcement by CMS that ICD-10 implementation will be delayed for certain healthcare entities, some industry pundits have argued, “Let’s just skip ICD-10 and go straight to ICD-11.”

Skipping ICD-10 assumes that we haven’t started implementing ICD-10. Well, the U.S. did start—19 years ago.

What have we been doing for the last 19 years?

Federal agencies kicked off ICD-10 implementation in 1993 by preparing to develop a clinical modification of ICD-10 (a U.S. version), then getting a grant and assigning a contractor to develop a clinical modification. Ditto for a procedure coding system.

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There is a big shift occurring in the way we measure the efficiency and effectiveness of health care. The shift is moving beyond process measures toward patient-satisfaction measures, such as CAHPS surveys and outcomes measures, including hospital-acquired conditions and hospital readmissions. These new measures are quickly becoming the foundation of new payment systems.

For example, the CMS hospital readmissions reduction program will penalize excessive hospital readmissions. This provides a huge incentive for hospitals to improve protocols and procedures to lower readmission rates. However, it isn’t just a clinical care issue. It’s a measurement issue, too, as pointed out by the Healthcare Financial Management Association (HFMA) in their letter to CMS. HFMA argues for CMS to provide data on readmissions and to change how they are defined and calculated. (They also made an unsolicited endorsement of 3M classification methodologies. Thanks, HFMA!)

Traditionally our industry has focused on quality process measures such as whether a medicine was delivered or not on time. Process measures are important. That’s a critical step in an equality hierarchy, but they’re not a measurement of the outcome of interest. If you’re trying to measure infection rates after surgery or a lung puncture or aspiration pneumonia, that’s the outcome.

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Part 1 of this series introduced the role of standard terminologies in meaningful use (MU). Part 2 illustrates some of the challenges encountered to support the implementation of MU.

Challenge #1: Many terminologies are needed to support the EHR and MU

Currently, no one terminology or classification system contains everything that is needed for the EHR, so encoding patient data for MU requires multiple standards. The Office of the National Coordinator for Health Information Technology (ONC) has adopted an initial set of vocabulary standards to support the proposed requirements of MU, shown in Table 1. Continue reading →

I am going to be brief about the recent HHS announcement to delay ICD-10 implementation. Fighting ICD-10 implementation is roughly as old as ICD-10, and the AMA and MGMA won this round. I only hope that whatever comes down the regulation pike, they will get some benefit that was worth the political capital spent on delaying ICD-10.

If an “unfunded mandate” becomes an “unfunded mandate delayed for two years,” whatever it is about ICD-10 that seems intolerable will still be there waiting. So let’s make use of whatever time we have. I will continue to share what I know about ICD-10 in the hope that it will make the transition easier for physicians.

As with just about every endeavor, the 80/20 rule can be applied to learning ICD-10 terminology for the needs of your practice. Your practice spends 80 percent of its time on the most common types of patients treated in your area of specialty. The remaining 20 percent include a variety of the less common and more complex cases. The latter cannot be handled as efficiently — in care and treatment or in coding. You deal with them as they come up.

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On Valentine’s Day, CMS sent a love note to the industry in the guise of a proposal, informing it of the need to report and return self-identified overpayments within 60 days of the incorrect payment identification or “on the date when a corresponding cost report is due, whichever is later.”

Twice before, in 1998 and 2002, CMS tried to enact changes to the amendment regulating recoupment of overpayments. The Health Care Education Reconciliation Act of 2010 (Pub.L.111-152) amended provision of Pub. L. 111-148 (Patient Protection and Affordable Care Act) to demand that providers and suppliers return any overpayments within the time frame stipulated above. Plus, the provider/supplier must inform the CMS in writing of the reason for the overpayment. In addition to providers and suppliers, this stipulation applies to Managed Care Organizations, Medicare Advantage Organizations, and Part D Plan sponsors, but not beneficiaries. Initially, the regulations will be amended to affect Part A and B providers and suppliers. For more see http://s3.amazonaws.com/public-inspection.federalregister.gov/2012-03642.pdfContinue reading →